NSQHS Standards

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National Safetyand Quality HealthService Standards

June 2011


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National Safety and Quality Health Service Standards, June 2011

ISBN print: 978-0-9870617-9-9

Suggested citation:Australian Commission on Safety and Quality in Heal th Care (ACSQHC) (2011), National Safety and Quality Health ServiceStandards, ACSQHC, Sydney.

Commonwealth of Australia 2011

This work is copyright. I t may be reproduced in whole or in par t for study or training purposes subject to the inclusion of anacknowledgement of the source. Requests and inquiries concerning reproduction and rights for purposes other than thoseindicated above requires the written permission of the Australian Commission on Safety and Quality in Health Care:

Australian Commission on Safety and Quality in Heal th CareGPO Box 5480Sydney NSW 2001Email: [email protected]

Acknowledgements

This document was prepared by the Australian Commission on Safet y and Quality in Health Care in collaboration with numerousexpert working groups and members of the Commissions standing committees who generously gave of their time andexpertise. Thanks also go to the numerous individuals and organisations, health services, practitioners, consumers, managersand health departments who have provided the feedback that made these Standards possible.


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National Safety and Quality Health Service Standards | 1

Contents

Introduction 3

Roles for Safety and Quality in Health Care 6

Terminology 7

Standard 1 Governance for Safety and Quality in HealthService Organisations 14

Standard 2 Partnering with Consumers 22

Standard 3 Preventing and Controlling HealthcareAssociated Infections 26

Standard 4 Medication Safety 34

Standard 5 Patient Identification and Procedure Matching 40

Standard 6 Clinical Handover 44

Standard 7 Blood and Blood Products 48

Standard 8 Preventing and Managing Pressure Injuries 54

Standard 9 Recognising and Responding to ClinicalDeterioration in Acute Health Care 60

Standard 10 Preventing Falls and Harm from Falls 66

Appendix 1 72

References 73


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The Hon Dr Kim Hames

Chair, Australian Health Ministers Conference

Minister for Health

AHMC Secretariat

PO Box 344

RUNDLE MALL SA 5000

Dear Minister

The National Safety and Quality Health Service Standards

On behalf of the Commission, I am honoured to submit the National Safety and Quality Health Service

Standardsfor the consideration of Health Ministers.

The Commission developed the Standards fol lowing extensive public and stakeholder consultation. The

Standards are a critical component of the Australian Health Services Safety and Quality Accreditation Scheme

endorsed by the Australian Health Ministers in November 2010.

The Standards provide a national ly consistent and uniform set of measures of safety and quality for application

across a wide variety of health care services. They propose evidence-based improvement strategies to deal

with gaps between current and best practice outcomes that affect a large number of patients.

The Standards address the following areas:

Governance for Safety and Quality in Health Service Organisations

Partnering with Consumers

Preventing and Controlling Healthcare Associated Infections

Medication Safety

Patient Identification and Procedure Matching

Clinical Handover

Blood and Blood Products

Preventing and Managing Pressure Injuries

Recognising and Responding to Clinical Deterioration in Acute Health Care

Preventing Falls and Harm from Falls

The Standards are designed to assist health service organisations to deliver safe and high quali ty care.The document presents the ten National Safety and Quality Health Service Standards and details the tasks

required to fulfil them.

I acknowledge the contribution, effort and enthusiasm of the many clinicians, managers, consumers and

organisations involved in their development. And I commend the diligence and commitment of our staff who

developed them.

Yours sincerely

William J Beerworth

Chair

19 May 2011


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Introduction

Australian Commission on Safety and Quality in Health Care

This document presents the ten National Safety andQuality Health Service (NSQHS) Standards. TheNSQHS Standards were developed by the AustralianCommission on Safety and Quality in Health Care(ACSQHC) in consultation and collaboration withjurisdictions, technical experts and a wide rangeof stakeholders, including health professionalsand patients.

The primary aims of the NSQHS Standards are toprotect the public from harm and to improve the

quality of health service provision. They provide aquality assurance mechanism that tests whetherrelevant systems are in place to ensure minimum

standards of safety and quality are met, and a qualityimprovement mechanism that allows health servicesto realise aspirational or developmental goals.

Accreditation is recognised as an impor tant driverfor safety and quali ty improvement and Australiashealth accreditation processes are highly regardedinternationally1. The Standards are integral to theaccreditation process as they determine how andagainst what an organisations performance will beassessed. The Standards have been designed for use

by all health services. Health service organisationscan use the Standards as part of their internal qualityassurance mechanisms or as part of an external

accreditation process.

National Safety and Quality Health Service Standards

1. Governance for Safety and Quality in Health Service Organisationswhich describesthe quality framework required for health service organisations to implement safe systems.

2. Partnering with Consumerswhich describes the systems and strategies to create a

consumer-centred health system by including consumers in the development and design of quality

health care.

3. Preventing and Controlling Healthcare Associated Infectionswhich describes the

systems and strategies to prevent infection of patients within the healthcare system and to

manage infections effectively when they occur to minimise the consequences.

4. Medication Safetywhich describes the systems and strategies to ensure clinicians safely

prescribe, dispense and administer appropriate medicines to informed patients.

5. Patient Identification and Procedure Matchingwhich describes the systems and strategies

to identify patients and correctly match their identity with the correct treatment.

6. Clinical Handoverwhich describes the systems and strategies for effective clinical

communication whenever accountability and responsibility for a patients care is transferred.

7. Blood and Blood Productswhich describes the systems and strateiges for the safe,

effective and appropriate management of blood and blood products so the patients receiving

blood are safe.

8. Preventing and Managing Pressure Injuries which describes the systems and strategies

to prevent patients developing pressure injuries and best practice management when pressure

injuries occur.

9. Recognising and Responding to Clinical Deterioration in Acute Health Carewhich

describes the systems and processes to be implemented by health service organisations to

respond effectively to patients when their clinical condition deteriorates.

10. Preventing Falls and Harm from Fallswhich describes the systems and strategies to reduce

the incidence of patient falls in health service organisations and best practice management when

falls do occur.


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Introduction

4 | National Safety and Quality Health Service Standards

Austral ian Commission on Safety and Quality in Health Care

The NSQHS Standards

Standard 1 Governance for Safety and Quality

in Health Service Organisations and Standard 2

Partnering with Consumers set the overarching

requirements for effective implementation of the

remaining eight Standards, which address specific

clinical areas of patient care.

Standard 1 provides the safety and quality framework

by outlining the expected structures and processes of

a safe organisation.

Standard 2 requires effective and meaningful

engagement of patients in the review, design and

implementation of services as there is evidence

that suggests that engaging patients can result in

improved safety, quality and efficiency.

The Standards address areas in which there are:

a large number of patients involved

known gaps between the current situation

and best practice outcomes

existing improvement strategies that are

evidence-based and achievable.

Content of theNSQHS Standards

Each Standard contains:

the Standard, which outlines the intended actions

and strategies to be achieved

a statement of intent, which describes the

intended outcome for the Standard

a statement on the context in which the Standard

must be applied

a list of key criteria; each criterion has a series

of items and actions that are required in order to

meet the Standard.

Core and developmental actions

The Standards apply to a wide var iety of health

services. Because of the variable size, structure,

and complexity of health service delivery models, a

degree of flexibility is required in the application of

the Standards.

To achieve this flexibil ity, each action within a

Standard is designated as either:

core, which are critical for safety and quality

or

developmental, which are aspirational targets.

Core actions are considered fundamental to safe

practice. Developmental actions identify areas where

health services can focus activities or investments

that improve patient safety and quality. Appendix 1

contains a schedule of actions that are developmental

for hospitals and day procedure services. A review of

all developmental actions is scheduled for 2015.


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Introduction


Ratings

The Commission has recommended that health

service organisations meet the requirements of the

Standards. Assessment will be against a three point

rating scale:

Not Met the actions required have not been

achieved.

Satisfactorily Met the actions required have

been achieved.

Met with Merit in addition to achieving the

actions required, measures of good quality

and a higher level of achievement are evident.

This would mean a culture of safety, evaluation

and improvement is evident throughout the

organisation in relation to the action or standard

under review.

This rat ing system will be used at the level of

individual actions in each Standard and can also

be applied to the overall Standard.In exceptional circumstances, a criterion, item

or action may be rated as not applicable. Not

applicable items are those that are inappropriate in

a service-specific context or for which assessment

would be meaningless.

Review of the Standards

Australian Health Ministers have charged the

ACSQHC with maintaining the Standards. After fu ll

implementation of the Standards an evaluation and

review will be undertaken to update and amend the

Standards. This review is scheduled for completion

by 2017.


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Roles for Safety and Quality in Health Care



This section outl ines the role for each group of

participants in ensuring the safe and effective

delivery of healthcare services in a health

service organisation.

Patients and carershave an important role to play

in the safe delivery of health care. As a partner with

health service organisations and their healthcare

providers, patients and carers will be involved in

making decisions for service planning, developing

models of care, measuring service and evaluating

systems of care. They will also participate in makingdecisions about their own health care and for this

they will need to know and exercise their healthcare

rights and be engaged in their health care and

treatment decisions. Patients and carers will have a

need to access information about options and agreed

treatment plans. Health care can be improved when

patients and carers share with their health care

provider issues that may impact on their compliance

with treatment plans.

The clinical workforceis essential to the delivery of

safe and high-quality health care. Improvement to thesystem can be achieved when the clinical workforce

actively participates in organisational processes,

safety systems, improvement initiatives, and is

trained in the roles and services for which they are

accountable. The clinical workforce can make health

systems safer and more effective if they:

understand their broad responsibility for safety

and quality in health care

follow safety and quality procedures

supervise and educate other members of the

workforce

participate in the review and analysis performance

procedures as an individual or as part of a team.

When the clinical workforce forms partnerships

with patients and carers, not only can a patients

experience of care be improved, but the design and

planning of organisational processes, safety systems,

quality initiatives and training can be more effective

as well.

The role of thenon-clinical work forceis also

important to the delivery of quality health care. This

workforce group may be paid or consist of volunteers.

By actively participating in organisational processes

including the development and implementation of

safety systems, improvement initiatives and related

training the limitations of safety systems can be

identified and addressed. A key role for this group is

notifying the clinical workforce when concerns exist

about a patient.

Health service managersimplement and maintainsystems, materials, education and training that ensure

the clinical workforce delivers safe, effective and

reliable health care. They support the establishment

of partnerships with patients and carers when

designing, implementing and maintaining systems.

Their key role is managing performance and

facilitating compliance across the organisation

and within individual areas of responsibility for

the governance of safety and quality systems.

They are leaders who can model behaviours that

optimise safe and high quality care. Safer systemscan be achieved when health service managers

consider safety and quality implications in their

decision-making processes.

The role ofhealth service executives and owners

is to plan and review integrated governance systems

that promote patient safety and quality and to

clearly articulate organisational and individual

accountabilities for safety and quality throughout

the organisation. The explicit support for the role

of patients and carers in safety, models of care,

program design and review of the organisationsperformance is key to the establishment of effective

partnerships with health service managers and the

clinical workforce.


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Terminology


Accreditation:A status that is conferred on an

organisation or an individual when they have been

assessed as having met particular standards. The two

conditions for accreditation are an explicit definition

of quality (i.e. standards) and an independent review

process aimed at identifying the level of congruence

between practices and quality standards.2

Acute health care facility:A hospital or other health

care facility providing healthcare services to patients

for short periods of acute illness, injury or recovery.3

ACSQHC:Australian Commission on Safety and

Quality in Health Care.

Advance care directive:Instructions that consent

to, or refuse the future use of, specified medical

treatments (also known as a healthcare directive,

advance plan or another similar term).3

Advanced life support:The preservation or

restoration of life by the establishment and/or

maintenance of airway, breathing and circulation

using invasive techniques such as defibrillation,advanced airway management, intravenous access

and drug therapy.3

Adverse drug reaction:A drug response that

is noxious and unintended, and which occurs at

doses normally used or tested in humans for the

prophylaxis, diagnosis or therapy of disease, or for

the modification of physiological function.4

Adverse event:An incident in which harm resulted

to a person receiving health care.

Adverse medicines event:An adverse event dueto a medicine. This includes the harm that results

from the medicine itself (an adverse drug reaction)

and the potential or actual patient harm that comes

from errors or system failures associated with the

preparation, prescribing, dispensing, distribution or

administration of medicines (medication incident).5

Antibiotic:A substance that kills or inhibits the

growth of bacteria.6

Antimicrobial:A chemical substance that inhibits

or destroys bacteria, viruses and fungi, including

yeasts or moulds.6

Antimicrobial stewardship:A program implemented

in a health service organisation to reduce the risks

associated with increasing microbial resistance and to

extend the effectiveness of antimicrobial treatments.

Antimicrobia l stewardship may incorporate a broadrange of strategies including the monitoring and

reviews of antimicrobial use.6

Approved patient identifiers: Items of information

accepted for use in patient identification, including

patient name (family and given names), date of

birth, gender, address, medical record number

and/or Individual Healthcare Identifier. Health

service organisations and clinicians are responsible

for specifying the approved items for patient

identification. Identifiers such as room or bed number

are not to be used.

Basic life support:The preservation of life by the

initial establishment of, and/or maintenance of, airway,

breathing, circulation and related emergency care,

including use of an automated external defibrillator.7

Blood: Includes homologous and autologous

whole blood. Blood including red blood cells,

platelets, fresh frozen plasma, cryoprecipitate and

cryodepleted plasma.8

Blood products:Plasma derivatives and recombinant

products, excluding medication products.8

Carers: People who provide unpaid care and support

to family members and friends who have a disability,

mental illness, chronic condition, terminal illness or

general frailty.9Carers include parents and guardians

caring for children.


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Terminology



Clinical communication:An exchange of

information that occurs between treating clinicians.

Communication can be formal (when a message

conforms to a predetermined structure for example in

a health record or stored electronic data) or informal

(when the structure of the message is determined

solely by the relevant parties; for example a face-to-

face or telephone conversation.10

Clinical governance:A system through which

organisations are accountable for continuously

improving the quality of their services andsafeguarding high standards of care. This is

achieved by creating an environment in which there

is transparent responsibility and accountability for

maintaining standards and by allowing excellence in

clinical care to flourish.11

Clinical handover:The transfer of professional

responsibility and accountability for some or all

aspects of care for a patient, or group of patients,

to another person or professional group on a

temporary or permanent basis.12

Clinical workforce:The nursing, medical and allied

health staff who provide patient care and students

who provide patient care under supervision. This may

also include laboratory scientists.13

Clinician:A healthcare provider, trained as a heal th

professional. Clinicians include registered and

non-registered practitioners, or a team of health

professionals providing health care who spend the

majority of their time providing direct clinical care.

Competency-based training:An approach totraining that places emphasis on what a person can

do in the workplace as a result of training completion.

Complementary healthcare products:Vitamin,

mineral, herbal, aromatherapy and homeopathic

products, also known as traditional or

alternative medicines.14

Consumer (health):Patients and potential

patients, carers and organisations representing

consumers interests.15

Consumer medicines information: Brand-specific

leaflets produced by a pharmaceutical company, in

accordance with the Therapeutic Goods Regulations(Therapeutic Goods Act 1989), to inform patients

about prescription and pharmacist-only medicines.

These are available from a var iety of sources: for

example, a leaflet enclosed within the medication

package or supplied by a pharmacist; or a computer

printout, provided by a doctor, nurse or hospital, and

obtaned from the pharmaceutical manufacturer or

from the internet.4

Continuous improvement:A systematic, ongoing

effort to raise an organisations performance as

measured against a set of standards or indicators.16

Disease surveillance:An epidemiological practice

that involves monitoring the spread of disease to

establish progression patterns. The main role of

surveillance is to predict, observe and provide a

measure for strategies that may minimise the harm

caused by outbreak, epidemic and pandemic

situations, as well as to increase knowledge of the

factors that might contribute to such circumstances.6

Emergency assistance: Clinical advice or assistance

provided when a patients condition has deterioratedseverely. This assistance is provided as part of the

rapid response system, and is additional to the care

provided by the attending medical officer or team.3

Environment:The overall surroundings where

health care is being delivered, including the building,

fixtures, fittings and services such as air and water

supply. Environment can also include other patients,

visitors and the workforce.


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Terminology


Escalation protocol:The protocol that sets out the

organisational response required for different levels

of abnormal physiological measurements or other

observed deterioration. The protocol applies to the

care of all patients at all times.3

Fall:An event that results in a person coming to

rest inadvertently on the ground or floor or another

lower level.17

Guidelines:Clinical practice guidelines are

systematically developed statements to assistpractitioner and patient decisions about appropriate

health care for specific circumstances.18

Governance:The set of relat ionships and

responsibilities established by a health service

organisation between its executive, workforce and

stakeholders (including consumers). Governance

incorporates the set of processes, customs, policy

directives, laws and conventions affecting the

way an organisation is directed, administered or

controlled. Governance arrangements provide the

structure through which the corporate objectives(social, fiscal, legal, human resources) of the

organisation are set and the means by which the

objectives are to be achieved. They also specify

the mechanisms for monitoring performance.

Effective governance provides a clear statement of

individual accountabilities within the organisation

to help in aligning the roles, interests and actions

of different participants in the organisation to

achieve the organisations objectives. In these

Standards, governance includes both corporate and

clinical governance.

Hand hygiene:A general term referring to any action

of hand cleansing.

Healthcare associated infections:Infections that

are acquired in healthcare facilities (nosocomial

infections) or that occur as a result of healthcare

interventions (iatrogenic infections). Healthcare

associated infections may manifest after people leave

the healthcare facility.19

Health outcome:The health status of an

individual, a group of people or a population that is

wholly or partially attributable to an action, agent

or circumstance.

Health service organisation:A separately

constituted health service that is responsible for

the clinical governance, administration and financial

management of a service unit(s) providing health care.

A service unit involves a grouping of clin icians and

others working in a systematic way to deliver health

care to patients and can be in any location or setting,

including pharmacies, clinics, outpatient facilities,

hospitals, patients homes, community settings,

practices and clinicians rooms.

Health service record: Information about a patientheld in hard or soft copy. The health service record

may comprise of clinical records (e.g. medical history,

treatment notes, observations, correspondence,

investigations, test results, photographs, prescription

records, medication charts), administrative records

(e.g. contact and demographic information, legal

and occupational health and safety reports) and

financial records (e.g. invoices, payments and

insurance information).

High-risk medicines: Medicines that have a high

risk of causing serious injury or death to a patient ifthey are misused. Errors with these products are not

necessarily more common, but the effects can be

more devastating. Examples of high-risk medicines

include anticoagulants, opioids and chemotherapy.20


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Terminology



Hospital:A healthcare facil ity licensed by the

respective regulator as a hospital or declared as

a hospital.

Human factors:Study of the interactions between

humans and other elements of a system, and the

profession that applies theory, principles, data and

methods to design in order to optimise human

wellbeing and overall system performance.21

Incident:An event or circumstance that resulted,

or could have resulted, in unintended and/orunnecessary harm to a person and/or a complaint,

loss or damage.

Infection:The invasion and reproduction of

pathogenic or disease-causing organisms inside

the body. This may cause tissue injury and disease.6

Infection control or infection control measures:

Actions to prevent the spread of pathogens between

people in a healthcare setting. Examples of infection

control measures include targeted healthcare

associated infection surveillance, infectiousdisease monitoring, hand hygiene and personal

protective equipment.6

Informed consent:A process of communication

between a patient and their medical officer that

results in the patients authorisation or agreement

to undergo a specific medical intervention.22This

communication should ensure the patient has an

understanding of all the available options and the

expected outcomes such as the success rates and/or

side effects for each option.23

Interventional procedures:Any procedure used

for diagnosis or treatment that penetrates the body.

These procedures involve incision, puncture, or entry

into a body cavity.

Invasive devices:Devices inserted through skin,

mucosal barrier or internal cavity, including central

lines, peripheral lines, urinary catheters, chest

drains, peripherally inserted central catheters and

endotracheal tubes.

Medication:The use of medicine for therapy or

for diagnosis, its interaction with the patient and

its effect.

Medication authorities:An organisations formal

authorisation of an individual, or group of individuals,

to prescribe, dispense or administer medicines or

categories of medicine consistent with their scope

of practice.

Medication error:Any preventable event that may

cause or lead to inappropriate medication use orpatient harm while the medication is in the control of

the healthcare professional, patient or consumer.24

Medication history:An accurate recording of a

patients of medicines. It comprises a list of all current

medicines including all current prescription and non-

prescription medicines, complementary healthcare

products and medicines used intermittently; recent

changes to medicines; past history of adverse

drug reactions including allergies; and recreational

drug use.25

Medication incident: SeeAdverse medicines event.

Medication management system:The system used

to manage the provision of medicines to patients.

This system includes dispensing, prescribing, storing,

administering, manufacturing, compounding and

monitoring the effects of medicines as well as the

rules, guidelines, decision-making and support tools,

policies and procedures in place to direct the use of

medicines. These are specific to a healthcare setting.

Medications reconciliation:The process of

obtaining, verifying and documenting an accurate

list of a patients current medications on admission

and comparing this list to the admission, transfer,

and/or discharge medication orders to identify and

resolve discrepancies. At the end of the episode of

care the verified information is transferred to the next

care provider.

Medicine:A chemical substance given with

the intention of preventing, diagnosing, curing,

controlling or alleviating disease, or otherwise

improving the physical or mental welfare of people.Prescription, non-prescription and complementary

medicines, irrespective of their administration route,

are included.26


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Terminology


Monitoring plan:A written plan that documents

the type and frequency of observations to be

recorded as referred to in Standard 9, Recognising

and Responding to Clinical Deterioration in Acute

Health Care.3

Near miss:An incident that did not cause harm, but

had the potential to do so.27

Non-clinical workforce:The workforce engaged

in a health service organisation who do not provide

direct clinical care but support the business of healthservice delivery through administration, hotel service

and corporate record management, management

support or volunteering.

Non-prescription medicines:Medicines available

without a prescription. Some non-prescription

medicines can be sold only by pharmacists or in a

pharmacy; others can be sold through non-pharmacy

outlets. Examples of non-prescription medicines

include simple analgesics, cough medicines

and antacids.26

Open disclosure:An open discussion with a patient

about an incident(s) that resulted in harm to that

patient while receiving health care. The criteria of

open disclosure are an expression of regret and a

factual explanation of what happened, the potential

consequences and the steps being taken to manage

the event and prevent recurrence.28

Orientation:A formal process of informing and

training workforce upon entry into a position or

organisation, which covers the policies, processes

and procedures applicable to the organisation.

Patient:A person receiving health care. Synonyms

for patient include consumer and client.

Patient-care mismatching events:Events where

a patient receives the incorrect procedure, therapy,

medication, implant, device or diagnostic test. This

may be as a result of the wrong patient receiving the

correct treatment (e.g. the wrong patient receiving an

X-ray) or as a result of the correct patient receiving

the wrong care (e.g. a surgical procedure performed

on the wrong side of the body or the provision of anincorrect meal, resulting in an adverse event).

Patient-centred care:The delivery of health care

that is responsive to the needs and preferences

of patients. Patient-centred care is a dimension of

safety and quality.

Patient clinical record:Consists of, but is not limited

to, a record of the patients medical history, treatment

notes, observations, correspondence, investigations,

test results, photographs, prescription records and

medication charts for an episode of care.

Patient information:Formal information that isprovided by health services to a patient. Patient

information ensures the patient is informed before

making decisions about their health care.

Patient blood management:Involves a

precautionary approach and aims to improve clinical

outcomes by avoiding unnecessary exposure to

blood components. It includes the three pillars of

blood managment:

optimisation of blood volume and red cell mass

minimisation of blood loss

optimisation of the patients tolerance of anaemia.29

Patient master index:An organisations

permanent listing or register of health information

on patients who have received or are scheduled

to receive services.30

Periodic review:Infrequent review, the frequency

of which is determined by the subject, risk, scale

and nature of the review.

Point of care:The time and location where an

interaction between a patient and clinician occursfor the purpose of delivering care.

Policy:A set of principles that reflect the

organisations mission and direction. All procedures

and protocols are linked to a policy statement.

Prescription medicine:A prescription medicine is

any medicine that requires a prescription before it can

be supplied. A prescription must be authorised by an

appropriately registered practitioner.31


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Terminology



Pressure injuries:These are localised to the

skin and/or underlying tissue, usually over a bony

prominence and caused by unrelieved pressure,

friction or shearing. Pressure injuries occur most

commonly on the sacrum and heel but can

develop anywhere on the body. Pressure injury is

a synonymous term for pressure ulcer.

Procedure:The set of instructions to make

policies and protocols operational and are specific

to an organisation.

Protocol:An established set of rules used for the

completion of tasks or a set of tasks.

Rapid response system:The system for providing

emergency assistance to patients whose condition is

deteriorating. The system includes the clinical team or

individual providing emergency assistance, and may

include on-site and off-site personnel.3

Recognition and response systems:Formal

systems that help workforce promptly and reliably

recognise patients who are clinically deteriorating,and appropriately respond to stabilise the patient.3

Regular:Performed at recurring intervals. The

specific interval for regular review, evaluation, audit or

monitoring and so on need to be determined for each

case. in these Standards, the time period should be

consistent with best practice, be risk based, and be

determined by the subject and nature of the review.

Risk:The chance of something happening that

will have a negative impact. It is measured by

consequences and likelihood.

Risk management:The design and implementation

of a program to identify and avoid or minimise risks

to patients, employees, volunteers, visitors and

the institution.

System:The resources, policies, processes and

procedures that are organised, integrated, regulated

and administered to accomplish the objective of the

Standard. The system:

Interfaces risk management, governance,

operational processes and procedures, including

education, training and or ientation

deploys an active implementation plan and

feedback mechanisms

includes agreed protocols and guidelines, decision

support and other resource material employs a range of incentives and sanctions to

influence behaviours and encourage compliance

with policy, protocol, regulation and procedures.

Training:The development of knowledge and skills.

Treatment-limiting orders: Orders, instructions

or decisions that involve the reduction, withdrawal

or withholding of life-sustaining treatment. These

may include no cardiopulmonary resuscitation or

not for resuscitation.3

Workforce:All those people employed by a health

service organisation.


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Standard 1 Governance for Safety and Quality

in Health Service Organisations

Standard 2 Partnering with Consumers

Standard 3 Preventing and Controlling Healthcare

Associated Infections

Standard 4 Medication Safety

Standard 5 Patient Identification and

Procedure Matching

Standard 6 Clinical Handover

Standard 7 Blood and Blood Products

Standard 8 Preventing and Managing

Pressure Injuries

Standard 9 Recognising and Respondingto Clinical Deterioration in Acute

Health Care

Standard 10 Preventing Falls and Harm from Falls


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Governance for Safety and Qualityin Health Service OrganisationsStandard 1

14 |


The intention of this Standard is to:

Create integrated governance systems that

maintain and improve the reliability and quality of

patient care, as well as improve patient outcomes.

Context:

This Standard provides the safety and quality

governance framework for health service

organisations. It is expected that this Standard

will apply to the implementation of all other

Standards in conjunction with Standard 2,

Partnering with Consumers.

Criteria to achieve the Governance

for Safety and Quality in Health

Service Organsations Standard:

Governance and quality

improvement systems

There are integrated systems of governance to

actively manage patient safety and quality risks.

Clinical practice

Care provided by the clinical workforce is guidedby current best practice.

Performance and skills management

Managers and the clinical workforce have the

right qualifications, skills and approach to provide

safe, high-quality health care.

Incident and complaints management

Patient safety and quality incidents are

recognised, reported and analysed, and this

information is used to improve safety systems.

Patient rights and engagement

Patient rights are respected and their engagement

in their care is supported.

The Governance for Safety and Quality in Health Service

Organisations Standard:

Health service organisation leaders implement governance systems to set, monitorand improve the performance of the organisation and communicate the importanceof the patient experience and quality management to all members of the workforce.Clinicians and other members of the workforce use the governance systems.


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Standard 1 Governance for Safety and Quality in Health Service Organisations

Explanatory notes

Although most health care in Austra lia is associated

with good clinical outcomes, patients still do not

always receive all the care that is recommended to

them, and preventable adverse events continue to

occur across the Australian healthcare system.32

Presently, the data that measures the extent to which

problems are occurring are unavailable or unreliable.

This prevents the establ ishment of a basel ine value

from which improvements in safety and quality of carecan be measured.

However, in recent years, there has been a shift in

both the awareness of, and investment in, safety and

quality by Australian health services. Health Service

organisations have developed and implemented

policy, educational materials and processes for

improvement (including credentialing, mor tality

reviews, incident monitoring and root-cause analysis).

These changes have improved the safety and quality

of health care for patients. Still, more needs to be

done to ensure all patients are protected from harm

and receive the highest possible standard of care.

Economic projections for total health expenditure

indicate that fiscal pressure on the system will only

rise in the future. An increase of $90.9 billion in total

health expenditure was predicted between 2003 and

203233.33This figure could be reduced or the rate

of increase slowed, if safer and higher quality care

is provided.

A systematic approach to quali ty improvement

identifies those accountable for action in healthservice organisations, and focuses on risk, quality

and patient safety to ensure that the necessary

monitoring and actions are taken to improve services.

Safety and high quality care requires the vigilance and

cooperation of the whole healthcare workforce.


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Standard 1

Governance for Safety and Qualityin Health Service Organisations



Governance and quality improvement systems

There are integrated systems of governance to actively manage patient safety and qual ity risks.

This criterion will be achieved by: Actions required:

1.1 Implementing a governance system

that sets out the policies, procedures

and/or protocols for:

establishing and maintaining a

clinical governance framework identifying safety and quality risks

collecting and reviewing

performance data

implementing prevention strategies

based on data analysis

analysing reported incidents

implementing performance

management procedures

ensuring compliance with legislative

requirements and relevant

industry standards

communicating with and informing the

clinical and non-clinical workforce

undertaking regular clinical audits

1.1.1An organisation-wide management system is in place for

the development, implementation and regular review of policies,

procedures and/or protocols

1.1.2The impact on patient safety and qual ity of care is

considered in business decision making

1.2The board, chief executive of ficer

and/or other higher level of governance

within a health service organisation

taking responsibility for patient safety and

quality of care

1.2.1 Regular reports on safety and quality indicators and other

safety and quality performance data are monitored by the

executive level of governance

1.2.2Action is taken to improve the safety and quali ty of

patient care

1.3Assigning workforce roles,

responsibilities and accountabilities to

individuals for:

patient safety and quality in their

delivery of health care

the management of safety and quality

specified in each of these Standards

1.3.1 Workforce are aware of their delegated safety and quality

roles and responsibilities

1.3.2 Individuals with delegated responsibilities are supported

to understand and perform their roles and responsibilities, in

particular to meet the requirements of these Standards

1.3.3Agency or locum workforce are aware of their designated

roles and responsibilities


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1.4 Implementing training in the

assigned safety and quality roles

and responsibilities

1.4.1Orientation and ongoing training programs provide the

workforce with the skill and information needed to fulfil their

safety and quality roles and responsibilities

1.4.2Annual mandatory training programs to meet the

requirements of these Standards1.4.3Locum and agency workforce have the necessary

information, training and orientation to the workplace to fulfil

their safety and quality roles and responsibilities

1.4.4Competency-based training is provided to the clinical

workforce to improve safety and quality

1.5Establishing an organisation-wide risk

management system that incorporates

identification, assessment, rating,

controls and monitoring for patient safetyand quality

1.5.1An organisation-wide risk register is used and

regularly monitored

1.5.2Actions are taken to minimise risks to patient safety

and quality of care

1.6Establishing an organisation-

wide quality management system that

monitors and reports on the safety

and quality of patient care and informs

changes in practice

1.6.1An organisation-wide quality management system

is used and regularly monitored

1.6.2Actions are taken to maximise patient quality of care


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Standard 1




Clinical practice

Care provided by the clinical workforce is guided by current best practice.


1.7 Developing and/or applying clinical

guidelines or pathways that are

supported by the best available evidence

1.7.1Agreed and documented clinical guidelines and/or

pathways are available to the clinical workforce

1.7.2The use of agreed clinical guidelines by the clinical

workforce is monitored

1.8Adopting processes to support the

early identification, early intervention and

appropriate management of patients at

increased risk of harm

1.8.1Mechanisms are in place to identify patients at increased

risk of harm

1.8.2Early action is taken to reduce the risks for at-risk patients

1.8.3Systems exist to escalate the level of care when there is an

unexpected deterioration in health status

1.9 Using an integrated patient clinical

record that identifies all aspects of the

patients care

1.9.1Accurate, integrated and readily accessible patient clinical

records are available to the clinical workforce at the point of care

1.9.2The design of the patient cl inical record al lows forsystematic audit of the contents against the requirements of

these Standards


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Performance and skills management

Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high

quality health care.


1.10Implementing a system that

determines and regularly reviews the

roles, responsibilities, accountabilities

and scope of practice for the

clinical workforce

1.10.1A system is in place to define and regularly review the

scope of practice for the clinical workforce

1.10.2Mechanisms are in place to monitor that the clinical

workforce are working within their agreed scope of practice

1.10.3 Organisational clinical service capability, planning and

scope of practice is directly linked to the clinical service roles

of the organisation

1.10.4The system for defining the scope of practice is used

whenever a new clinical service, procedure or other technology

is introduced

1.10.5Supervision of the clinical workforce is provided whenever

it is necessary for individuals to fulfil their designated role

1.11Implementing a performancedevelopment system for the clinical

workforce that supports performance

improvement within their scope

of practice

1.11.1A valid and reliable performance review process is in placefor the clinical workforce

1.11.2The clinical workforce participates in regular performance

reviews that support individual development and improvement

1.12Ensuring that systems are in place

for ongoing safety and quality education

and training

1.12.1The clinical and relevant non-clinical workforce have

access to ongoing safety and quality education and training

for identified professional and personal development

1.13Seeking regular feedback fromthe workforce to assess their level of

engagement with, and understanding

of, the safety and quality system of

the organisation

1.13.1Analyse feedback from the workforce on theirunderstanding and use of safety and quality systems

1.13.2Action is taken to increase workforce understanding

and use of safety and quality systems


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Standard 1




Incident and complaints management

Patient safety and quality incidents are recognised, reported and analysed, and this information is used to

improve safety systems.


1.14Implementing an incident

management and investigation system

that includes reporting, investigating

and analysing incidents (including

near misses), which all result incorrective actions

1.14.1Processes are in place to support the workforce

recognition and reporting of incidents and near misses

1.14.2Systems are in place to analyse and report on incidents

1.14.3Feedback on the analysis of reported incidents isprovided to the workforce

1.14.4Action is taken to reduce risks to patients identified

through the incident management system

1.14.5Incidents and analysis of incidents are reviewed at

the highest level of governance in the organisation

1.15Implementing a complaints

management system that includes

partnership with patients and carers

1.15.1Processes are in place to support the workforce

to recognise and report complaints

1.15.2Systems are in place to analyse and implement

improvements in response to complaints

1.15.3Feedback is provided to the workforce on the analysis

of reported complaints

1.15.4Patient feedback and complaints are reviewed at

the highest level of governance in the organisation

1.16Implementing an open disclosure

process based on the national open

disclosure standard

1.16.1An open disclosure program is in place and is consistent

with the national open disclosure standard

1.16.2The clinical workforce are trained in open

disclosure processes


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Patient rights and engagement

Patient rights are respected and their engagement in their care is supported.


1.17Implementing through organisational

policies and practices a patient charter of

rights that is consistent with the current

national charter of healthcare rights34

1.17.1The organisation has a charter of patient rights that is

consistent with the current national charter of healthcare rights

1.17.2Information on patient rights is provided and explained

to patients and carers

1.17.3Systems are in place to support patients who are at risk ofnot understanding their healthcare rights

1.18Implementing processes to enable

partnership with patients in decisions

about their care, including informed

consent to treatment

1.18.1 Patients and carers are partners in the planning for their

treatment

1.18.2Mechanisms are in place to monitor and improve

documentation of informed consent

1.18.3 Mechanisms are in place to align the information provided

to patients with their capacity to understand

1.18.4Patients and carers are supported to document clear

advance care directives and/or treatment-limiting orders

1.19Implementing procedures that

protect the confidentiality of patient

clinical records without compromising

appropriate clinical workforce access to

patient clinical information

1.19.1Patient clinical records are available at the point of care

1.19.2 Systems are in place to restrict inappropriate access

to and dissemination of patient clinical information

1.20Implementing well designed, valid

and reliable patient experience feedback

mechanisms and using these to evaluate

the health service performance

1.20.1Data collected from patient feedback systems are used to

measure and improve health services in the organisation


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Partnering with ConsumersStandard 2

22 |



Create a health service that is responsive to

patient, carer and consumer input and needs.

Context:

This Standard provides the framework for active

partnership with consumers by health service

organisations. It is expected that this Standard

will apply in conjunction with Standard 1,

Governance for Safety and Quality in Health

Service Organisations, in the implementation

of all other Standards.

Criteria to achieve the Partneringwith Consumers Standard:

Consumer partnership in service planning

Governance structures are in place to form

partnerships with consumers and/or carers.

Consumer partnership in designing care

Consumers and/or carers are supported by the

health service organisation to actively participate

in the improvement of the patient experience and

patient health outcomes.

Consumer partnership in service

measurement and evaluation

Consumers and/or carers receive information on

the health service organisations per formance

and contribute to the ongoing monitoring,

measurement and evaluation of performance for

continuous quality improvement.

The Partnering with Consumers Standard:

Leaders of a health service organisation implement systems to support partneringwith patients, carers and other consumers to improve the safety and quality ofcare. Patients, carers, consumers, clinicians and other members of the workforceuse the systems for partnering with consumers.


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Explanatory notes

There is growing evidence about the importance of

partnerships between health service organisations

and health professionals, and patients, families,

carers and consumers. Studies have demonstrated

significant benefits from such partnerships in clinical

quality and outcomes, the experience of care, and

the business and operations of delivering care. The

clinical benefits that have been identified as being

associated with better patient experience and patient-centred care include:

decreased mortality35

decreased readmission rates36

decreased rates of healthcare acquired infections37

reduced length of stay38

improved adherence to treatment regimens39

improved functional status.38

Operational benefits that have been identified include

lower costs per case, improved liability claims

experiences, and increased workforce satisfactionand retention rates.40

The importance of health systems and health services

that are based on partnerships with patients, families,

carers and consumers is reflected in national and

international quality frameworks.39In Australia,

consumer-centred care is one of the three dimensions

in the Australian Safety and Quality Framework

for Health Care.40Partnerships with patients and

consumers also form the basis of a range of national

and jurisdictional health policies and programs.


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Standard 2

Partnering with Consumers



Consumer partnership in service planning

Governance structures are in place to form partnerships with consumers and/or carers.


2.1 Establishing governance structures

to facilitate partnerships with consumers

and/or carers

2.1.1Consumers and/or carers are involved in the governance of

the health service organisation

2.1.2Governance partnerships are reflective of the diverse

range of backgrounds in the population served by the health

service organisation, including those people who do not usuallyprovide feedback

2.2 Implementing policies, procedures

and/or protocols for partnering with

patients, carers and consumers in:

strategic and operational/services

planning

decision making about safety

and quality initiatives

quality improvement activities

2.2.1The health service organisation establishes mechanisms

for engaging consumers and/or carers in the strategic and/or

operational planning for the organisation

2.2.2Consumers and/or carers are actively involved in decision

making about safety and quality

2.3Facilitating access to relevant

orientation and training for consumers

and/or carers partnering with the

organisation

2.3.1Health service organisations provide orientation and

ongoing training for consumers and/or carers to enable them to

fulfil their partnership role

2.4 Consulting consumers on

patient information distributed by

the organisation

2.4.1Consumers and/or carers provide feedback on patient

information publications prepared by the health service

organisation (for distribution to patients)

2.4.2Action is taken to incorporate consumer and/or carers

feedback into publications prepared by the health service

organisation for distribution to patients


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Consumer partnership in designing care

Consumers and/or carers are supported by the health service organisation to actively participate in the

improvement of the patient experience and patient health outcomes.


2.5 Partnering with consumers

and/or carers to design the way care

is delivered to better meet patient

needs and preferences

2.5.1 Consumers and/or carers participate in the design and

redesign of health services

2.6Implementing training for clinical

leaders, senior management and the

workforce on the value of and ways to

facilitate consumer engagement and how

to create and sustain partnerships

2.6.1Clinical leaders, senior managers and the workforce

access training on patient-centred care and the engagement

of individuals in their care

2.6.2Consumers and/or carers are involved in training the

clinical workforce

Consumer partnership in service measurement and evaluation

Consumers and/or carers receive information on the health service organisations performance and contribute

to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.


2.7Informing consumers and/or carers

about the organisations safety and

quality performance in a format that

can be understood and interpreted

independently

2.7.1The community and consumers are provided with

information that is meaningful and relevant on the organisations

safety and quality performance

2.8 Consumers and/or carersparticipating in the analysis of safety

and quality performance information

and data, and the development and

implementation of action plans

2.8.1Consumers and/or carers participate in the analysisof organisational safety and quality performance

2.8.2Consumers and/or carers participate in the planning and

implementation of quality improvements

2.9 Consumers and/or carers

participating in the evaluation of patient

feedback data and development of

action plans

2.9.1Consumers and/or carers participate in the evaluation of

patient feedback data

2.9.2Consumers and/or carers participate in the implementation

of quality activities relating to patient feedback data


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Preventing and ControllingHealthcare Associated InfectionsStandard 3

26 |



Prevent patients from acquiring preventable

healthcare associated infections and

effectively manage infections when they occur

by using evidence-based strategies.

Context:

It is expected that this Standard will be applied

in conjunction with Standard 1, Governance

for Safety and Quality in Health Service

Organisations and Standard 2, Partnering

with Consumers.

Criteria to achieve the Preventing and

Controlling Healthcare Associated

Infections Standard:

Governance and systems for infection

prevention, control and surveillance

Effective governance and management systems for

healthcare associated infections are implemented

and maintained.

Infection prevention and control strategies

Strategies for the prevention and control of healthcare

associated infections are developed and implemented.

Managing patients with

infections or colonisations

Patients presenting with, or acquiring an infection or

colonisation during their care are identified promptly

and receive the necessary management and treatment.

Antimicrobial stewardship

Safe and appropriate antimicrobial prescribing is a

strategic goal of the clinical governance system.

Cleaning, disinfection and sterilisation

Healthcare facilities and the associated

environment are clean and hygienic. Reprocessing

of equipment and instrumentation meets current

best practice guidelines.

Communicating with patients and carers

Information on healthcare associated infections

is provided to patients, carers, consumers andservice providers.

The Preventing and Controlling Healthcare Associated

Infections Standard:

Clinical leaders and senior managers of a health service organisation implementsystems to prevent and manage healthcare associated infections and communicatethese to all workforce to achieve appropriate outcomes. Clinicians and othermembers of the workforce use the healthcare associated infection prevention and

control systems.


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Standard 3 Preventing and Controlling Healthcare Associated Infections

Explanatory notes

Infectious organisms evolve over time and continue

to present new challenges for infection prevention

and management within health care. Of major current

concern is the emergence and transmission of

antimicrobial resistant bacteria, such as methicillin-

resistant Staphylococcusaureus(MRSA) and

vancomycin-resistant enterococci (VRE). Other

new challenges have arisen with the increase of

infection with Closiridium difficileand multi-resistantGram-negative bacteria, including those producing

extended-spectrum beta-lactamases (ESBLs) or

carbapenemases.

In Australian healthcare settings, large numbers

of patients are treated in close proximity to each

other. They often undergo invasive procedures, have

medical devices inserted and receive broad-spectrum

antibiotics or immunosuppressive therapies. These

conditions provide ideal opportunities for the adaption

and spread of pathogenic, infectious organisms.

Each year, infections associated with health

care occur in a large number of patients, making

healthcare associated infections the most common

complication affecting patients in hospitals. Some of

these infections require stronger and more expensive

medicines (with the added risk of complications),

and may result in life-long disabilities or even death.

In addition to significant patient harm caused by

healthcare associated infections, such infections

increase patient use of health services (such as

extending length of stay and reducing access to

available beds) and place greater demands on the

clinical workforce (such as laboratory tests and other

tools to diagnose the infection).

At least half of healthcare associated infections are

preventable. Australian and overseas studies have

shown that mechanisms exist that can reduce the

rate of infections caused by these agents.

Infection prevention and control aims to reduce the

development of resistant pathogens and minimise risk

of transmission through the isolation of the infectious

organism or the patient, and by using standard and

transmission-based precautions. However, just as

there is no single cause of infection, there is no

single solution to the problems posed by healthcare

associated infections. Successful infection control

requires a range of strategies across all levels of

the healthcare system and a collaborative approach

for successful implementation. These strategiesinclude infection control, hand hygiene surveillance

and improving the safe and appropriate use of

antimicrobials through antimicrobial stewardship.

Systems and governance for infection prevention,

control and surveillance must be consistent with

relevant national documents, includingAustral ian

Guidelines for the Prevention and Control of Infections

in Health Care.19


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Standard 3

Preventing and ControllingHealthcare Associated Infections



Governance and systems for infection prevention, control and surveillance

Effective governance and management systems for healthcare associated infections are implemented

and maintained.


3.1Developing and implementing

governance systems for effective

infection prevention and control to

minimise the risks to patients of

healthcare associated infections

3.1.1A risk management approach is taken when implementing

policies, procedures and/or protocols for:

standard infection control precautions

transmission-based precautions aseptic non-touch technique

safe handling and disposal of sharps

prevention and management of occupational exposure to

blood and body substances

environmental cleaning and disinfection

antimicrobial prescribing

outbreaks or unusual clusters of communicable infection

processing of reusable medical devices

single-use devices

surveillance and reporting of data where relevant

reporting of communicable and notifiable diseases

provision of risk assessment guidelines to workforce

exposure-prone procedures

3.1.2The use of policies, procedures and/or protocols is

regularly monitored

3.1.3The effectiveness of the infection prevention and control

systems is regularly reviewed at the highest level of governance

in the organisation

3.1.4Action is taken to improve the effectiveness of infection

prevention and control policies, procedures and/or protocols

3.2Undertaking surveillance of

healthcare associated infections

3.2.1Surveillance systems for healthcare associated

infections are in place

3.2.2Healthcare associated infections surveillance

data are regularly monitored by the delegated workforce

and/or committees


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systems and processes for reporting,

investigating and analysing healthcare

associated infections, and aligning

these systems to the organisations riskmanagement strategy

3.3.1Mechanisms to regularly assess the healthcare associated

infection risks are in place

3.3.2Action is taken to reduce the risks of healthcare

associated infection

3.4Undertaking quality improvement

activities to reduce healthcare associated

infections through changes to practice

3.4.1Quality improvement activities are implemented to reduce

and prevent healthcare associated infections

3.4.2Compliance with changes in practice are monitored

3.4.3The effectiveness of changes to practice are evaluated


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Standard 3




Infection prevention and control strategies

Strategies for the prevention and control of healthcare associated infection are developed and implemented.


3.5 Developing, implementing and

auditing a hand hygiene program

consistent with the current national hand

hygiene initiative43

3.5.1Workforce compliance with current national hand hygiene

guidelines is regularly audited

3.5.2Compliance rates from hand hygiene audits are regularly

reported to the highest level of governance in the organisation

3.5.3Action is taken to address non-compliance, or the inabilityto comply, with the requirements of the current national hand

hygiene guidelines


monitoring a risk-based workforce

immunisation program in accordance

with the current National Health and

Medical Research Council Australian

immunisation guidelines44

3.6.1A workforce immunisation program that complies with

current national guidelines is in use

3.7Promoting collaboration with

occupational health and safety programs

to decrease the risk of infection or injury

to healthcare workers

3.7.1Infection prevention and control consultation related to

occupational health and safety policies, procedures and/or

protocols are implemented to address:

communicable disease status

occupational management and prophylaxis

work restrictions

personal protective equipment

assessment of risk to healthcare workers for

occupational allergies

evaluation of new products and procedures

3.8 Developing and implementing a

system for use and management of

invasive devices based on the current

national guidelines for preventing and

controlling infections in health care19

3.8.1Compliance with the system for the use and management

of invasive devices is monitored

3.9 Implementing protocols for invasive

device procedures regularly per formed

within the organisation

3.9.1Education and competency-based training in invasive

devices protocols and use is provided for the workforce who

perform procedures with invasive devices


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3.10 Developing and implementing

protocols for aseptic non-touch technique

3.10.1The clinical workforce is trained in aseptic

non-touch technique

3.10.2Compliance with aseptic non-touch technique is

regularly audited

3.10.3Action is taken to increase compliance with the aseptic

non-touch technique protocols

Managing patients with infections or colonisations

Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and

receive the necessary management and treatment.


3.11Implementing systems for using

standard precautions and transmission-

based precautions

3.11.1Standard precautions and transmission-based precautions

consistent with the current national guidelines are in use

3.11.2Compliance with standard precautions is monitored

3.11.3Action is taken to improve compliance withstandard precautions

3.11.4 Compliance with transmission-based precautions

is monitored

3.11.5Action is taken to improve compliance with

transmission-based precautions

3.12Assessing the need for patient

placement based on the risk of infection

transmission

3.12.1A risk analysis is undertaken to consider the need for

transmission-based precautions including:

accommodation based on the mode of transmission

environmental controls through air flow transportation within and outside the facility

cleaning procedures

equipment requirements


protocols relating to the admission,

receipt and transfer of patients with

an infection

3.13.1Mechanisms are in use for checking for pre-existing

healthcare associated infections or communicable disease on

presentation for care

3.13.2A process for communicating a patients infectious

status is in place whenever responsibility for care is transferred

between service providers or facilities


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Standard 3




Antimicrobial stewardship

Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.



regularly reviewing the effectiveness of

the antimicrobial stewardship system

3.14.1An antimicrobial stewardship program is in place

3.14.2The clinical workforce prescribing antimicrobials

have access to current endorsed therapeutic guidelines

on antibiotic usage45

3.14.3Monitoring of antimicrobial usage and resistanceis undertaken

3.14.4Action is taken to improve the effectiveness of

antimicrobial stewardship

Cleaning, disinfection and sterilisation

Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and

instrumentation meets current best practice guidelines.


3.15Using risk management principles to

implement systems that maintain a clean

and hygienic environment for patients

and healthcare workers

3.15.1Policies, procedures and/or protocols for environmental

cleaning that address the principles of infection prevention

and control are implemented, including:

maintenance of building facilities

cleaning resources and services

risk assessment for cleaning and disinfection based

on transmission-based precautions and the infectious

agent involved

waste management within the clinical environment

laundry and linen transportation, cleaning and storage appropriate use of personal protective equipment

3.15.2Policies, procedures and/or protocols for environmental

cleaning are regularly reviewed

3.15.3An established environmental cleaning schedule is in

place and environmental cleaning audits are undertaken regularly

3.16 Reprocessing reusable medical

equipment, instruments and devices

in accordance with relevant national

or international standards andmanufacturers instructions

3.16.1Compliance with relevant national or international

standards and manufacturers instructions for cleaning,

disinfection and sterilisation of reusable instruments and devices

is regularly monitored


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3.17Implementing systems to enable the

identification of patients on whom the

reusable medical devices have been used

3.17.1A traceability system that identifies patients who have

a procedure using sterile reusable medical instruments and

devices is in place

3.18 Ensuring workforce who

decontaminate reusable medical devices

undertake competency-based training

in these practices

3.18.1Action is taken to maximise coverage of the relevant

workforce trained in a competency-based program to

decontaminate reusable medical devices


Information on healthcare associated infection is provided to patients, carers, consumers and service

providers.


3.19Ensuring consumer-specific

information on the management and

reduction of healthcare associatedinfections is available at the point of care

3.19.1Information on the organisations corporate and clinical

infection risks and initiatives implemented to minimise patient

infection risks is provided to patients and/or carers3.19.2 Patient infection prevention and control information

is evaluated to determine if it meets the needs of the

target audience


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Medication SafetyStandard 4

34 |



Ensure competent clinicians safely prescribe,

dispense and administer appropriate medicines to

informed patients and carers.

Context:

It is expected that this Standard will be applied

in conjunction with Standard 1, Governance

for Safety and Quality in Health Service

Organisations and Standard 2, Partnering

with Consumers.

Criteria to achieve the MedicationSafety Standard:

Governance and systems

for medication safety

Health service organisations have mechanisms

for the safe prescribing, dispensing, supplying,

administering, storing, manufacturing,

compounding and monitoring of the effects

of medicines.

Documentation of patient information

The clinical workforce accurately records a

patients medication history and this history

is available throughout the episode of care.

Medication management processes

The clinical workforce is supported for the

prescribing, dispensing, administering, storing,

manufacturing, compounding and monitoring

of medicines.

Continuity of medication management

The clinician provides a complete list of a

patients medicines to the receiving clinician

and patient when handing over care or

changing medicines.


The clinical workforce informs patients about their

options, risks and responsibilities for an agreed

medicines management plan.

The Medication Safety Standard:

Clinical leaders and senior managers of a health service organisation implementsystems to reduce the occurrence of medication incidents, and improve thesafety and quality of medicine use. Clinicians and other members of theworkforce use the systems to safely manage medicines.


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Standard 4 Medication Safety


Explanatory notes

Medicines are the most common treatment used in

health care. Because they are so commonly used,

medicines are associated with a higher incidence

of errors and adverse events than other healthcare

interventions. Some of these events are costly and

potentially avoidable.

Over 1.5 million Australians are estimated to

experience an adverse event from medicines each

year.46This results in at least 400 000 visits to general

practitioners and 190 000 hospital admissions47,

which represents 23% of all admissions. As

many as 30% of unplanned geriatric admissions

are associated with an adverse medicine event.5

Approximately 50% of these admissions are

considered potentially avoidable.48

The cost of these adverse events to individual

patients and the healthcare system is significant.

A study published in 2009 reported that medicine-

related hospital admissions in Australia wereestimated to cost $660 million.47The impact on

patients quality of life is more difficult to quantify.

Many solutions to prevent medication errors are found

in standardisation and systemisation of processes.

Other recognised solutions for reducing common

causes of medication errors include:

improving clinician-workforce and clinician-patient

communication

using technology to support information

recording and transfer

providing better access to patient information andclinical decision support at the point of care.


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Standard 4

Medication Safety


Governance and systems for medication safety

Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering,

storing, manufacturing, compounding and monitoring of the effects of medicines.



governance arrangements and

organisational policies, procedures

and/or protocols for medication safety,

which are consistent with national andjurisdictional legislative requirements,

policies and guidelines

4.1.1Governance arrangements are in place to support the

development, implementation and maintenance of organisation-

wide medication safety systems

4.1.2Policies, procedures and/or protocols are in place that areconsistent with legislative requirements, national, jurisdictional

and professional guidelines

4.2 Undertaking a regular,

comprehensive assessment of

medication use systems to identify risks

to patient safety and implementing

system changes to ad

Documents

NSQHS Standards